A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

Wear an N95 respirator when providing direct client care.

Make sure the client's room has positive-pressure airflow.

Make sure dietary plates and utensils are disposable.

Monitor the client's temperature once every 6 hr.

Answer and Explanation

The Correct Answer is B

A)   While wearing an N95 respirator may be necessary for certain infections, it is not a routine precaution for clients in protective isolation.
B)   Ensuring the client's room has positive-pressure airflow helps prevent the entry of airborne pathogens into the room, reducing the risk of infection for the immunocompromised client.
C)   Using disposable plates and utensils helps reduce the risk of cross-contamination and infection transmission but is not directly related to airborne infection control.
D)   Monitoring the client's temperature is important for assessing for signs of infection, but it does not directly prevent infection transmission in the same way as positive-pressure airflow.

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Correct Answer is ["Pain level","ECG results"]

Explanation

The client's pain level should be addressed first based on the principle of prioritizing interventions according to the client's immediate needs and potential severity of the condition. Chest pain, especially when radiating to the left arm, is a concerning symptom that can indicate myocardial ischemia or infarction. It is essential to promptly assess and manage the client's pain to provide relief and potentially mitigate further cardiac damage. In this scenario, the client rates the pain as 7 out of 10, indicating moderate to severe discomfort, which warrants immediate attention.

A. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L B. Initiate cardiac monitoring C. Regular insulin 20 units subcutaneously D. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L E. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr F. Dextrose 5% in water (D5W) intravenous at 5 ml/kg/hr for 4 hr G. Blood glucose checks every 4 hr H. Monitor urine outputs

Correct Answer is ["D","E","H"]

Explanation

A. This prescription addresses hypokalemia. Potassium chloride is administered intravenously to help normalize potassium levels within the desired range. However, in this case the patient’s potassium is 5.5 hence does not require potassium chloride.

B. The client has mild hyperkalemia; hence, continuous cardiac monitoring is prudent to detect any potential arrhythmias or changes in cardiac status. However, the priority interventions are insulin therapy, hydration, and urinary catheter insertionto monitor input and output.

C. Subcutaneous insulin administration may be appropriate for clients with diabetes mellitus, but in this case, the client's blood glucose level is critically high, and they may be experiencing diabetic ketoacidosis (DKA), which requires rapid correction. Subcutaneous insulin administration would not provide the prompt and aggressive treatment required for DKA.

D. This prescription addresses the client's hyperglycemia and acidosis indicated by the blood glucose level of 468 mg/dL and pH of 7.30, respectively. Continuous intravenous insulin infusion is the standard treatment for diabetic ketoacidosis (DKA) to lower blood glucose levels and correct acidosis.

E. This prescription addresses the client's dehydration indicated by the elevated blood glucose level, decreased blood pressure, and slight tenting of the skin. Intravenous fluid resuscitation with 0.9% sodium chloride is initiated to restore intravascular volume and correct electrolyte imbalances.

F. Administering D5W intravenously is contraindicated in the setting of hyperglycemia and diabetic ketoacidosis (DKA) because it would exacerbate the already elevated blood glucose levels. D5W contains glucose and would further increase blood glucose levels, worsening the client's condition.

G. While monitoring blood glucose levels is important for clients with diabetes, checking it every 4 hours is not sufficient in this scenario, especially given the client's markedly elevated blood glucose level of 468 mg/dL and symptoms suggestive of diabetic ketoacidosis (DKA). Therefore, blood glucose levels should be monitored at least hourly.

H. Monitoring urine output is important in clients with diabetes and dehydration. Therefore, inserting an indwelling urinary catheter is important in this scenario.

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A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's Select... followed by the client's Select...ECG results

Correct Answer is ["Pain level","ECG results"]

Explanation

A nurse is caring for a client in the emergency department. Exhibits Which of the following 3 provider prescriptions does the nurse anticipate?

Correct Answer is ["D","E","H"]

Explanation

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